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ealthcare providers Module 1: Rationale for Lifestyle & Weight Management Counseling

Yale-Griffin Prevention Research Center www.yalegriffinprc.org

1

Summary of Modules

•

Module 1

provides an overview of the obesity epidemic and explains the importance of lifestyle counseling to promote health.

•

Module 2

provides guidance for nutrition and physical activity prescriptions for weight management and optimum health.

•

Module 3

reviews theories of behavior modification.

•

Module 4

presents the Pressure System Model, a behavior change construct tailored to, and tested in, the primary care setting. 2

Obesity – The Problem

3

World Pandemic

• According to the WHO, 1.6 billion adults worldwide were overweight in 2005.

• At least 400 million adults were obese.

• At least 20 million children <5 years were overweight.

• WHO predicts that 2.3 billion adults will be overweight and 700 million will be obese by the year 2015.

• http://www.who.int/mediacentre/factsheets/fs311/en/index.html

4

World Pandemic

• The United States can be regarded as the epicenter of this global pandemic. • Overweight and obesity affects 65%-80% of American adults, and a rising proportion of children.

• Obesity is a major, modifiable risk factor for type 2 diabetes and cardiovascular disease.

Katz DL. (2007) Nutrition in Clinical Practice. Lippincott Williams & Wilkins 5

Obesity Trends Among U.S. Adults

According to the CDC’s Behavioral Risk Factor Surveillance System (BRFSS): – In 1995, obesity prevalence in each of the 50 states was less than 20%. – In 2000, 28 states had obesity prevalence rates less than 20%.

– In 2005, 4 states had obesity prevalence rates less than 20%.

– In 2007, 1 state (Colorado) had obesity prevalence rate less than 20%.

www.cdc.gov/nccdphp/dnpa/obesity/index.htm

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Obesity Trends* Among U.S. Adults

BRFSS, 1990, 1998, 2007 (*BMI



30, or about 30 lbs. overweight for 5’4” person) 1990 1998 2007 No Data <10% 10%–14% 15%–19% 20%–24% 25 %–29% ≥30%

Increase in Prevalence (%) of Overweight and Obesity Among U.S. Adults

1976 - 1980 1988 - 1994 1999 - 2000 2001 - 2002 2003 – 2004 Overweight (BMI > 25)

47.0

55.9

64.5

65.7

66.2

Obesity (BMI > 30)

15.0

23.2

30.9

31.3

32.9

CDC national center for health statistics

9

Increase in Overweight Prevalence (%) Among U.S. Children & Adolescents

AGE 2 – 5 1971 1974

5

6 - 11

4

12 - 19

6.1

1976 1980

5 6.6

5

1988 1994

7.2

11.3

10.5

1999 2000

10.3

15.1

14.8

2001 – 2002

10.6

16.3

16.7

2003 2004

13.9

18.8

17.4

CDC, National Center for Health Statistics, National Health and Nutrition Examination Survey 10

Lifestyle Counseling- The Why 11

Cost of Obesity Related Illness in the U.S.

1987 2002 % Increase

Average $ Cost Normal Weight Obese

$1,512 $1,784 $2,210 $3,454 46 % 94 %

% Difference

15 % 36 % 48 %

Cost in years of life lost :

• average of 7.1 years of life for women •average 5.8 years of life for men 12

Cost of Obesity in the U.S.

13

Definitions of Overweight and Obesity

14

Adults

Population weight trends are measured using the body mass index (BMI) which is the weight in kilograms divided by the height in meters squared (BMI=kg/m 2 )

Weight Category

Underweight Normal Overweight Obese I Obese II Obese III

BMI

<18.5

18.5-24.9

25-29.9

30-34.9

35-39.9

<40 15

Children

• • Growth charts show the weight status categories used with children and teens.

www.cdc.gov/nchs/about/major/nhanes/growthcharts/charts.htm

Weight Category

Underweight Healthy weight At risk of overweight Overweight

Percentile Range

<5 th percentile 5 th - 84.9

th percentile 85 th - 94.9

th percentile ≥ 95 th percentile 16

Medical Conditions Associated with Obesity

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• • • • • • • •

Health Effects of Obesity

Medicare reclassified obesity as a chronic disease in July, 2004.

Evidence shows that obesity and Type 2 diabetes are inflammatory states.

Co-morbidities concurrent with obesity lead to increased morbidity and mortality.

Prevalence of high blood pressure, high cholesterol and low HDL escalates with increasing BMI.

A 10% weight loss can improve some co-morbidities including type 2 diabetes and hypertension. Surgical removal of adipose tissue does not improve metabolic parameters.

http://obesity1.tempdomainname.com/subs/fastfacts/Health_Effects.shtml

Spiegelman . Adipocytes as regulators of energy balance and glucose homeostasis. Nature:2006 vol:444; 7121:847 -53 N Engl J Med. 2004;350:2542-2544, 2549-2557

Obesity and Mortality

• • Obesity is associated with increased overall mortality.

Mortality was found to be lowest at BMI of 22.5-25. Each 5 kg/m(2) higher BMI was on average associated with about 30% higher overall mortality.

• Whitlock G, Lewington S, Sherliker P, et al. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. The Lancet 2009; 373 iss:9669:1083 -96 19

• • • • • • • • • • • • •

Obesity = Increased Risk

Endometrial, colorectal, prostate, pancreatic, breast, esophageal and renal cell cancers Hypertension, cardiovascular disease, DVT, CVA Osteoarthritis, rheumatoid arthritis, gout, carpal tunnel syndrome, low back pain Type 2 Diabetes; Gall bladder disease Menstrual abnormalities, infertility, stress incontinence Asthma, sleep apnea, respiratory impairment

The incidence of co-morbidities related to obesity and overweight. BMC Public Health 2009, Mar 25:9:88 Callee et al. Obesity, recreational physical activity, and risk of pancreatic cancer in a large U.S. Cohort. Cancer Epid

Biomarkers Prev, 2005 Feb;14(2):459-66

Callee et al. Body mass index, weight change, and risk of prostate cancer in the Cancer Prevention Study II Nutrition

Cohort. Cancer Epid Biomarkers Prev. 2007 Jan;16(1):63-9. A prospective study of waist circumference and body mass index in relation to colorectal cancer incidence. Cancer Causes Control. 2008 Sep;19(7):783-92

Callee et al. The role of body weight in the relationship between physical activity and endometrial cancer: results from a

large cohort of US women. Int J Cancer. 2008 Oct 15;123(8):1877-82 Maguire M. Impact of obesity on women's health. Fertility and Sterility, May 2009 Vol 91, Issue 5. American Obesity Association 20

Prevalence of Medical Conditions by BMI for Men

Medical Condition 18 – 24.9

Body Mass Index 25 – 29.9

30 – 34.9

Type 2 Diabetes 2.03

Coronary Heart Disease High Blood Pressure Osteoarthritis Source: NHANES III, 1988 - 1994.

8.84

23.47

2.59

Prevalence Ratio (%) 4.93

10.10

9.60

34.16

16.01

48.95

4.55

4.66

≥40 10.65

13.97

64.53

10.04

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Prevalence of Medical Condition by BMI for Women

Medical Condition 18.5 – 24.9

Body Mass Index 25 – 29.9

30 – 34.9

≥40 Type 2 Diabetes Coronary Heart Disease High Blood Pressure Osteoarthritis Source: NHANES III, 1988 - 1994.

2.38

6.87

23.26

5.22

Prevalence Ratio (%) 7.12

7.24

11.13

38.77

8.51

12.56

47.95

9.94

19.89

19.22

63.16

17.19

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Risk Factors for Obesity Associated Disease

Non-modifiable Risk Factors:

• Age – men over 45, women over 55 or after menopause.

• Gender – greater risk for men than women who are pre menopausal.

• Family History - first degree blood relative who experiences heart disease or stroke before the age of 55 years in a male and 65 years in a female.

Modifiable Risk Factors:

• Physical inactivity • Poor nutritional habits • • • High cholesterol High blood pressure Diabetes mellitus • Cigarette smoking 23

Abdominal Obesity

• • • • The presence of excess fat in the abdomen is an independent risk factor for morbidity and mortality. Waist circumference is strongly correlated with abdominal fat and provides a clinically acceptable measurement of abdominal fat content.

Waist circumference and BMI should be included in clinical assessment. Risk of obesity and associated diseases is increased if waist circumferences are: • • > 40 inches for men > 35 inches for women Despres JP. Abdominal obesity: the most prevalent cause of metabolic syndrome and related cardiometabolic risk. European Heart Journal 2006; 8: B4-B-12. 24

Disease Risk Relative to Weight and Waist Class Circumference BMI (kg/m 2 ) Normal Waist Circumference Increased Waist Circumference

Underweight <18.5

-- -- Normal 18.5 – 24.9

-- -- Overweight Obese I Obese II Obesity III 25 – 29.9

30 – 34.9

35.9 – 39.9

Increased High Very High ≥ 40 Extremely High High Very High Very High Extremely High 25

Pathways related to Obesity

Hofbauer KG. Molecular pathways to obesity. International Journal of Obesity 2002; 16:S18- S27. 26

Nutrition and Physical Activity in Weight Management

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Energy Balance

• • • Although genetics and the environment are contributing factors in deterring body fat mass accumulation, energy balance is of paramount importance in weight regulation.

If intake is too high obesity will develop.

Maintaining an appropriate energy balance of food intake and physical activity is a crucial preventive measure . • • Hofbauer KG. Molecular pathways to obesity. International Journal of Obesity 2002; 16: S18- S27.

Current Trends in Weight Management: What Advice Do We Give to Patients? Clinical Diabetes • Volume 26, Number 3, 2008 28

• • • • •

Physical Activity and a Healthful Diet

A healthful diet and physical activity are crucial components of weight loss/control.

Recent research shows 76% of US adults had inadequate fruit & vegetable intake and 65% did not exercise.

Eating well and being active have been linked to the prevention of co morbidities related to obesity and weight gain, such as diabetes and the metabolic syndrome.

Interventions during the phase of insulin resistance, particularly supervised weight loss, mitigate cardiovascular risk and prevent diabetes. Behavioral changes for long-term adherence are key components.

• • • Balasubramanian BA, Cohen DJ, Clark EC, Isaacson NF. Practice-level approaches for behavioral counseling and patient health behaviors. Am J Prev Med; 2008 Nov;35:S407-13.

Hu FB et al. NEJM. 2001;345:790-7 Magkos et al. Management of the Metabolic Syndrome and Type 2 Diabetes Through Lifestyle Modification. Annu. Rev. Nutr. 2009. 29:8.1–8.34r 29

The Diabetes Prevention Program (DPP)

• • • • • A randomized clinical trial to prevent type 2 diabetes in persons at high risk.

3,234 non-diabetics with elevated fasting and post load plasma glucose concentration.

Participants’ mean age was 51, mean BMI was 34, 68% were women, and 45% minorities. Randomly assigned to: – Placebo – – Metformin (850mg twice daily) Lifestyle modification program Follow-up was 2.8 years.

Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. NEJM 2002; 346: 393 403.

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DPP - Lifestyle Modification Arm

• • Goals of the lifestyle modification intervention: achieve ≥ 150 minutes of physical activity per week and a weight loss of > 7%.

Participants were encouraged to consume a healthy low-calorie, low-fat diet (based on the Food Guide Pyramid and the National Cholesterol Education Program) and to engage in moderate intensity physical activity (e.g., brisk walking). 31

DPP - Results

• The incidence of diabetes was 11.0, 7.8, and 4.8 cases per 100 person-years in the placebo, metformin, and lifestyle group respectively.

• The lifestyle group reduced the incidence of diabetes by 58%, and metformin by 31% in comparison to the placebo. 32

40 30

Cumulative Incidence of Diabetes-DPP

Percent developing diabetes

Type 2 Diabetes Prevention

Risk reduction 31% by metformin 58% by lifestyle Placebo Metformin 20 Lifestyle 10 0 0 1 2 Years from randomization 3 4 The DPP Research Group, NEJM 346:393-403, 2002 Lifestyle Counseling- The Why 33

DPP - Conclusion

• To prevent one case of diabetes during a period of three years, 7 people would have to participate in the lifestyle-intervention program, and 14 would have to receive metformin. • Lifestyle changes and treatment with metformin both reduced the incidence of diabetes in persons at high risk. The lifestyle intervention was more effective than metformin.

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DPP Prevalence of Metabolic Syndrome

• • • • 53% of participants were determined to have metabolic syndrome at baseline.

Lifestyle intervention and Metformin reduced development of the syndrome in the remaining participants (lifestyle intervention 38%; Metformin 23%).

Conclusion: Lifestyle changes may reverse metabolic syndrome and diabetes risk.

Orchard T, Temprosa M, Goldberg R. The effect of metformin and intensive lifestyle intervention on the metabolic syndrome: the Diabetes Prevention Program randomized trial. Annals of Internal Medicine:2005 vol:142 iss:8 pg:611 -9 35

Clustering of Risk Factors in the Metabolic Syndrome

Includes risk factors not routinely measured: – Insulin resistance – Small dense LDL – Endothelial dysfunction – Abnormal sympathetic nervous system activity – Pro-thrombotic markers—PAI-1, fibrinogen – Pro-inflammatory markers such as CRP 36

ATP III: The Metabolic Syndrome

Diagnosis is established when > 3 of these risk factors are present Risk Factor Defining Level Abdominal obesity (Waist circumference) Men Women TG HDL-C Men Women >102 cm (>40 in) >88 cm (>35 in) >150 mg/dL <40 mg/dL <50 mg/dL Blood pressure Fasting glucose >130/≥85 mm Hg >110 mg/dL - Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.

- http://www.nhlbi.nih.gov/guidelines/cholesterol/ 37

Lifestyle Counseling- The Why 38

Finnish Diabetes Prevention Study Does Treating Metabolic Syndrome Make a Difference?

   522 middle-aged, overweight adults, (BMI 31) 172 men and 350 women Mean duration 3.2 years  Intervention Group: Individualized counseling to  Reduce body weight and reduce dietary fat & saturated fat  Increase dietary fiber and physical activity  Control Group  Usual care; annual physical exam  General dietary and exercise advice at baseline Tuomilehto J et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. NEJM 2001; 344: 1343-1350. 39

Finnish Diabetes Prevention Study- Results Goals

Wt reduction >5% Fat intake < 30% energy Sat fat <10% energy

Intervention Control % of subjects

43 47 26 Fiber >15 g/1000 kcal 25 Exercise > 4 hr/wk 86 13 26 11 12 71

P value

0.001

0.001

0.001

0.001

0.001

40

Benefit of Treating the Metabolic Syndrome

Intervention

After 4 years — 23%

(17–29 CI)

risk of diabetes reduced by 11%

( 6–15 CI)

58%

Intervention Control % with Diabetes

Tuomilehto J et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. NEJM 2001; 344: 1343-1350. 41

Metabolic Syndrome: Benefits of Weight Loss

• Reverses insulin resistance, lowers metabolic syndrome and diabetes incidence in children and adults.

• Lowers systolic and diastolic blood pressure, glucose levels, cholesterol and TG. Savoye M et al. Effects of a weight management program on body composition and metabolic parameters in overweight children. JAMA 2007; 2697- 2704. Case CC et al. Impact of weight loss on the metabolic syndrome. Diabetes, Obesity, and Metabolism 2002; 4: 407-414.

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Set Point Theory and Weight Loss

• The set point theory emphasizes that the body has a homeostatic feedback system for controlling its fat stores.

• Homeostatic mechanisms are an adaptation of the body’s metabolic rate to maintain fat stores and body weight.

• A reduction in the consumption of calories without adding physical activity will result in a decline in the Resting Metabolic Rate (RMB), thus inhibiting weight loss.

• Combining physical activity and caloric restriction is the best way to achieve sustainable weight loss. • • Weinsier RL. Do Adaptive changes in metabolic rate favor weight regain in weight-reduced individuals? An examination of the set point theory. Am J Clin Nutr 2000; 72: 1088-1094. • Wang et al. Weight regain is related to decreases in physical activity during weight loss. Med Sci Sports Exerc. 2008 Oct;40(10) .

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Physical Activity

• A large body of scientific evidence has shown that physical activity has a protective effect against numerous chronic diseases and mortality.

• Sufficient physical activity = at least moderately active for 30 minutes or more on most days of the week.

• This amount of exercise can decrease risk of metabolic syndrome.

• Resistance training 2 days/week is recommended to promote lean body mass and muscle strength.

• • • • • • • Health care providers can play an important role in encouraging physical activity.

www.cdc.gov/nccdphp/sgr/pdf/sgrfull.pdf

; Jakicic JM, Marcus BH, Gallagher KI, et al. Effects of exercise duration and intensity on weight loss in overweight, sedentary woman.

JAMA 2003; 290: 1323-1330. Blair S, LaMonte M, Nichaman M. The evolution of physical activity recommendations: how much is enough? Am J Clin Nutr. 2004; 79 (5) Verghese J, Lipton RB, Katz MJ, et al. Leisure activities and risk of dementia in the elderly. NEJM 2003; 348: 2508-2516. Ainsworth BE, Youmans CP. Tools for physical activity counseling in medical practice. Obesity Research 2002; 10: 69S- 78S.

Johnson J, Slentz C, Houmard J, et al. Exercise training amount and intensity effects on metabolic syndrome. Am J Cardol; 2007 Dec 15;100(12):1759-66. 44

Physical Activity has a Protective Effect against:

Hypertension (SR of RCTs) Diabetes mellitus (Cs, RCTs, D) Dyslipidemia (Cs, RCTs, D) Obesity (Cs, RCTs, D) Myocardial infarction (Cs, D) Stroke (Cs, D), Claudication (SR of RCTs) Depression (SR of RCTs) Cognitive dysfunction (Cs, D) Osteoporosis (SR of RCTs) Arthritis (SR of RCTs) Chronic low back pain (SR of RCTs) Levels of evidence: Recurrent falls (SR of RCTs) Hip fracture (Cs) Breast cancer (SR of Cs, D) Colon cancer (SR of Cs, D) Chronic fatigue (RCTs) Fibromyalgia (RCTs) Sleep disorders (RCTs) Gallbladder stones (Cs, D) Diverticulosis (Cs) Prostate hypertrophy (Cs, D) Sexual dysfunction (RCTs) SR- systematic review RCTs- randomized controlled trials Cs- Cohort studies D- Dose-dependent effect 45

Physical Activity: Protective Mechanisms

• • • • • • • • Peripheral vasodilation (by nitric oxide) Enhanced sensitivity to insulin Increased HDL cholesterol Increased endogenous thrombolysis Improved musculoskeletal stability Enhanced cognitive function Improved mood Gene regulation 46

Physical Activity Prolongs Life

• • Physical activity or smoking cessation has been found to lower the mortality rate by 50% and increase survival rates by 10 years.

In comparison, Coronary Artery Bypass Graft (CABG) or catheterization prolongs life for a half a year.

•

10 8 Survival Benefit (years) 4 6 0 2 Coronary Revascularisation Smoking Cessation or Physical Activity

Yusuf S. Effect of coronary artery bypass graft surgery on survival: overview of 10-years results from randomized trial by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 1994; 344: 563-570.

Van de Werf. Access to catheterization facilities in patients admitted with acute coronary syndrome: multinational registry study. BMJ 2005; 330: 441-447.

Doll R. Mortality in relation to smoking: 50 years observations on male British doctors. BMJ 2004; 328: 1519-1527.

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Hypertension Studies:

• • • • • • • A meta-analysis by Whelton (2002) has shown that aerobic exercise is associated with a significant reduction in mean systolic and diastolic blood pressure (-3.84mm Hg and 2.58 mm Hg respectively). The reduction was seen in both normotensive and hypertensive patients alike. An increase in aerobic physical activity should be considered an important component of lifestyle modification for prevention and treatment of high blood pressure. According to the JNC7, aerobic physical activity is recommended for pre-hypertension and hypertension stages I and II.

In overweight hypertensive patients, a combined exercise and weight-loss intervention has been shown to decrease SBP and DBP by 12.5 and 7.9 mm Hg, respectively.

Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: A meta-analysis of randomized, controlled trials. Annals of Internal Medicine 2002; 136: 493-506. Appel L, Champagne C, Harsha D. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA; 2003 Apr 23-30;289(16):2083-93.

www.nhlbi.nih.gov/guidelines/hypertension/ 48

Physical Activity and Cancer

• • • Current research supports the beneficial role of physical activity and exercise in reducing the risk for developing breast cancer and preventing or attenuating disease and treatment-related impairments.

An inverse association exists between physical activity and colon cancer in both men and women.

Overweight or obesity increases risk of endometrial, breast, prostate, and colorectal cancers.

• • • Reigle B, Wonders K. Breast cancer and the role of exercise in women. Methods Mol Bio. 2009;472:169-89.

Wolin K, et al. Physical activity and colon cancer prevention: a meta-analysis. Br J Cancer; 2009 Feb 24;100(4):611-6. www.cdc.. gov/cancer/dcpc/prevention/ 49

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51

Lifestyle Counseling

52

Barriers to Lifestyle Counseling

 Lack of time within patient-provider encounter.

 Lack of knowledge and training in behavioral counseling.

 Lack of financial incentives.

 Unavailability of easily administered counseling tools.

Katz DL et al. Impact of an educational intervention on internal medicine residents' physical activity counseling: The Pressure System Model.

Journal of Evaluation in Clinical Practice.

In Press.

53

Patient-Provider Encounter

• Americans average 2.7 office visits per person per year, with most (60%) occurring in a primary care setting. • Patients regard physicians as a resource for preventive health information and recommendations.

• Many patients would like their doctor to focus more on prevention.

• Patients counseled by primary care physicians to make lifestyle changes and who target a specific change are more likely to make an attempt and to be successful.

Calfas et al., PACE+ for adults, 2002 54

Examples of Successful Programs

• The Green Prescription Intervention • PACE+ • The Pressure System Model (PSM)

55

The Green Prescription Intervention

• • • A 12- month physical activity counseling program in a primary care setting.

Physicians were trained in Motivational Interviewing and effective ways of incorporating physical activity counseling into the point of care using exercise prescriptions and follow-up with exercise specialists for three months.

Results indicated a statistically significant increase in physical activity levels, energy expenditure and quality of life in the intervention group compared to the control group.

Elley CR et al. Effectiveness of counseling patients on physical activity in general practice: cluster randomized controlled trial. BMJ 2003; 326: 793. 56

PACE+

for Adolescents

 A primary care-based physical activity and nutritional counseling program using an interactive computer program and focusing on provider counseling to target one physical activity behavior and one nutritional behavior in need of change.

 Results showed significant improvement over a 4 month period:  Decreased fat consumption   Increased fruit and vegetable intake Increased physical activity  Adolescents who set an a-priori goal of behavior change were more likely to change behaviors than those who did not set such goals.

940- 946. 57

The Pressure System Model Study (PSM)

• A controlled trial evaluated the impact of an educational intervention on clinician physical activity counseling behavior and their patients’ physical activity levels using the PSM in a busy primary care setting.

• At a 6 and 12 month follow-ups, patient physical activity increased significantly from baseline, compared to no change in the control.

• At 12 months, the intervention clinicians provided physical activity counseling 1.5 more times than they did at baseline. In comparison, no change was observed in residents in the control.

Katz DL, Shuval K, Comerford BP, Faridi Z, Njike VY. Impact of an educational intervention on internal medicine residents' physical activity counselling: the Pressure System Model. J Eval Clin Pract. 2008 Apr;14(2):294-9 58

Summary of Module 1

• • • • There is strong evidence associating sedentary lifestyle and weight gain to increased morbidity and mortality.

Weight loss and control have enormous potential health benefits. Lifestyle counseling in primary care can effectively encourage healthful dietary and physical activity patterns. The next module provides the information needed to provide an exercise prescription and offer constructive nutritional guidance.

59